CPT Knowledgebase - Feb 3, 2012

Regarding the use of code 88387, CPT codebook indicates that All aspects of the extended macro-scopic examination and dissection performed under sterile conditions were extensively documented. In our prac-tice, when a portion of the tissue is selected for molecular testing, we document this in the gross description as, Tissue submitted to XYZ lab for molecular analysis. Is this documentation sufficient? Or should we enhance our documentation to include the extended macroscopic exam under sterile conditions in order to better support the service rendered and assigned code 88387?

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